Managing Inappropriate Behavior in a 75-Year-Old Male Resident with Dementia

1. Unwanted Advances Sexuality Case

2. Presentation • 75-year old ambulatory male • Routinely touches female staff members when they are bathing, toileting or dressing him • No particular staff members as targets • Says “I’m sorry” when CNAs ask him to stop, then does it again • Now seen touching a female resident in her room

3. Ongoing Medical Conditions • Dementia • Heart disease • High blood pressure • Hypothyroidism • Enlarged prostate/ incontinence • Skin cancer • Constipation • Arthritis • Restless Leg Syndrome

4. Recent Medical Issues • None

5. Medications • Aricept and Namenda • Lasix • Metoprolol • Synthroid • Flomax • Senna/MOM/Fleets/Colace • Ultram/APAP/Vicodin • Mirapex

6. Medical Assessment • Possible causes • Medical conditions • Medication-induced hyperthyroidism • Dementia • Elevated testosterone level • Mania • Delirium • Medications • Mirapex

7. Medical Assessment • Laboratory tests • CBC and BMP are normal • UA is normal • Thyroid tests are normal • Testosterone level is low

8. Medical Management • Assumed to be secondary to dementia • 5-10% of dementia patients display hypersexuality • Mirapex discontinued • Clonazepam added for RLS • No other medication changes made • Possible use of other medications • No FDA indication • Certain antidepressants • Hormone treatment

9. Nursing Management • The resident is noted to target younger CNAs and nurses • More mature caregivers • Male caregivers employed when possible • Use a white jacket, other props • To more fully identify the female caregiver as a nurse • Scheduled caregiving • Rapid, safe completion of task • Care plan protocol for this issues posted in medical chart, on MAR

10. Nursing Management • Patient monitored in public areas • Behavior documented on an hourly basis • Encouraged to sit with male residents or less vulnerable females • Male staff help as much as possible with activities, meals • No mixed messages sent • More physically demonstrative female staff encouraged to refrain from supportive hugs, hand holding, using terms of endearment (“Honey”) with the resident • Firm, clear and calm redirection • “Please stop” rather than “That’s inappropriate”

11. Nursing Management • Make sure is not misidentification • Believes person(s) are spouse or girlfriend • Make sure nursing assistant concerns are addressed • Embarrassment • Disgust • Education about this as part of the illness is a must • Uncomfortable for residents, staff and families

12. Outcome • Elimination of Mirapex • May have been helpful • No need to move onto other agents • Nursing interventions • Cut down on frequency of events • No further incidents with other residents • New staff orientation discussed these issues • Care plan placed on chart, on MAR, for nursing staff less familiar with resident was effective